Cognitive Behavioral Therapy and Alcohol Abuse and Substance Addiction
Alcohol and substance abuse is a critical health concern in the USA. The statistics by the National Survey on Drug Use and Health shows that about 19.7 million people in America were victims of substance use disorder in the year 2017. The statistics shows that 74% of this population suffered from alcohol use disorder. Alcohol and drug use disorder is associated with adverse health effects that include addiction, low quality of life and loss of productivity. Therapeutic interventions have been developed for use in the treatment of alcohol and drug abuse. Therefore, the purpose of this paper is to examine the use of cognitive behavioral therapy in the treatment of alcohol and drug addiction.
Cognitive behavioral therapy is a psychotherapeutic intervention that is used in treatment of substance abuse disorder, including alcohol and drug addiction. The therapy works by helping patients to address their problematic feelings as well as thoughts attributed to addiction. Therapists help patients to identify their negative feelings and thoughts and their management using meaningful and positive interventions. The use of the therapy enables patients to develop effective coping skills for managing addiction. The history of cognitive behavioral therapy dates back to the 1960s when it was developed by Dr. Aaron Beck while working at the University of Pennsylvania. Dr. Beck found that depressed patients demonstrated consistent negative thoughts that were spontaneous in nature. Dr. Beck further found that the negative thoughts could be eliminated or managed by helping patients to re-evaluate them and thoughts about themselves, hence, the development of the resilience that patients needed in managing their daily functions and minimizing the harms associated with negative feelings and thoughts (Sadock & Sadock, 2020). Since then, the use of cognitive behavioral therapy for the treatment of different mental health problems such as depression, anxiety and addiction among others have been explored in studies.
Cognitive behavioral therapy has its basis on operant and classical conditioning, social learning as well as research on human cognitive processes. The therapy operates on the beliefs that negative stimulus develops from repeated exposure and pairing of the stimulus with relevant stimulus that produces unlearned biological response. The theory also is based on the belief that environmental stimuli may increase or decrease the risk of behavior development, which has an effect on the mental, psychological and emotional wellbeing of an individual (Ash et al., 2021). The interaction between different stimuli therefore influences individual behavior and response to their environmental needs.
A number of principles guide cognitive behavioral therapy. One of them is the belief that problematic behaviors arise from learned interactions with the environment. The behaviors can be unlearned for individual’s optimal functioning. The therapy also operates on the principle that least complex problems should be prioritized in psychological treatments. The complex issues should be considered if the adopted interventions are ineffective. In addition, cognitive behavioral therapy is based on scientific knowledge that influences the accuracy and safety of the adopted interventions (Barry et al., 2019). For example, therapists develop hypotheses that guide the interventions and assessment of their effectiveness in the management of psychological problems.
Cognitive behavioral theory in its use in alcohol and substance abuse addiction therefore believes that substance abuse is a learned behavior. The onset as well as continuation of substance abuse largely depends on the positive expectancies that are associated with the substance abuse and by social influence of significant others such as family members and friends. The therapy further acknowledges the fact that aspects such as behaviors, norms, and stress coping may impel individuals to abuse alcohol and substances in their settings. Cognitive behavioral therapy can therefore be administered individually or in a group to achieve its desired therapeutic effectiveness. Its use in either individual or group therapy aims at reducing the positive expectancies of the patients about substance abuse and improving the self-confidence and self-efficacy of the patients towards resisting substance misuses and enhancing their coping skills (Ibemere, 2020). Consequently, cognitive behavioral therapy focuses on social learning, stress and coping, behavioral economics, and social control for the victims of alcohol and substance abuse.
Treatment Approach and Guidelines
Several cognitive behavioral treatment approaches exist for use in the management of alcohol abuse and drug addiction. The treatment approaches are largely classified into those that focus on cognitive development and those focusing on behavioral aspects of managing alcohol and drug addiction. The cognitive techniques aim at the beliefs and thoughts that predispose patients to engaging in addictive behaviors. The fundamental skill in cognitive techniques entail identifying and differentiating the core thoughts, beliefs, emotions and behaviors of the addicts. Patients are assisted in identifying their negative thoughts and emotions to enable the utilization of complex cognitive techniques such as exposure-based strategies arousal reduction, and assertive training (Magill et al., 2019). Part of the cognitive techniques include teaching patients the skills related to rational decision making where patients are guided to understand the benefits and risks of making specific choices related to addictive behaviors.
Cognitive behavioral techniques in substance abuse and addiction aim at modifying the unhealthy behaviors that predispose the patients to alcohol and substance abuse. Therapists largely rely on methods such as physical exercises, relaxation training, assertiveness training as well as activity scheduling to help patients modify their unhealthy behaviors. Contingency management therapies have also proven effective where patients are given incentives for achieving specific behavioral goals. Contingency management therapies utilize principles of operant condition where the aim is to achieve sustained utilization of the prescribed interventions for addiction management (Kapadia, 2020). Skills training therapies are effective in helping patients identify the high-risk situations that predispose them to drug abuse and strategies that they can utilize to cope with them. Motivational interviewing is also used where patients are assisted to develop the intrinsic motivation to change. The additional cognitive behavioral techniques utilized in alcohol and substance addiction include couple and family treatments and drug counseling. A specific guideline for cognitive behavioral therapy for use in patients with alcohol abuse and addiction does not exist. Cognitive behavioral therapy is indicated for use in a wide range of mental health problems that include anxiety, depression, obsessive compulsive disorders, addiction, post-traumatic stress disorder, eating disorder, psychosis, and panic disorders (López et al., 2021).
Basic Training and Certification
Evidence has shown that APRNs are uniquely positioning to provide cognitive behavioral therapy that exceeds the care needs of patients with alcohol and substance abuse problems. However, their ability to provide cognitive behavioral therapy for alcohol and substance abuse disorders is currently restricted due to the lack of clear pathway on issues such as training opportunities as well as credentialing. Therefore, it is not mandatory for APRNs to be trained on cognitive behavioral therapy (Ibemere, 2020). However, they can enroll in training programs to enhance their knowledge and skills in the use of cognitive behavioral therapy in the management of different mental health problems.
Cognitive behavioral therapy has been shown to be highly effective for a wide range of disorders, including alcohol and substance abuse and addiction. However, the majority of the existing research on cognitive behavioral therapy has largely utilized western populations. The emerging evidence has begun to focus on the use of cognitive behavioral therapy for ethnic minority groups in the USA and other global states. Cognitive behavioral therapy may be effective in addressing the need of patients from ethnic and diverse backgrounds (Hinton & Patel, 2017). However, there is an increasing need to ensure that the cognitive behavioral therapy that patients receive is culturally adaptive. Accordingly, individuals from different ethnic backgrounds have unique cultural values, beliefs and practices. The diversity in beliefs, values and practices imply that the existing cognitive behavioral interventions should be culturally sensitive (Naeem, 2019). Culturally sensitive or adaptive cognitive behavioral therapy has been shown to be highly effective when compare to unadapted cognitive behavioral therapy.
Cognitive behavioral therapy should be modified to account for culture, language and contexts of the diverse populations affected by alcohol and substance abuse. Accordingly, standard techniques should be framed in a way that they are more tolerable to individuals from diverse ethnicities and psychopathologies. The need for the modification of cognitive behavioral therapy should also be targeted at eliminating local stigma associated with mental health problems. Healthcare providers should also be prepared to provide culturally adaptive cognitive behavioral therapy to patients with alcohol and substance abuse. They should be provided with training opportunities that increase their competencies in the delivery of culturally appropriate cognitive behavioral therapy (Naeem, 2019). Through such interventions, healthcare organizations and providers will create positive expectancy as well as treatment credibility in the delivery of culturally appropriate cognitive behavioral therapy.
Several studies have been conducted over the recent past to determine the effectiveness of cognitive behavioral therapy in substance abuse disorders. One of these studies is the research by Magill et al. (2019). Magill et al. (2019) conducted a research that aimed at determining the effectiveness of cognitive behavioral therapy in alcohol and other drug use disorders. The investigation was a meta-analysis of 30 randomized controlled trials. The analysis of the data in this study showed that cognitive behavioral therapy was associated with moderate to significant effect size in all the selected randomized controlled studies. The authors therefore recommended that cognitive behavioral therapy should be used in the treatment of alcohol and substance abuse disorders to enhance coping and recovery process.
Roos et al. (2017) conducted a study that aimed at examining whether the baseline dependence severity was attributed to mediating effect of cognitive behavioral therapy in alcohol abuse disorders. The study used 1063 patients with alcohol abuse disorder. The analysis of data cognitive behavioral therapy enhanced the coping skills of participants who had history of alcohol abuse disorder. Cognitive behavioral therapy also lessened the severity of symptoms by enhancing the coping skills that the participants developed in the study.
The feasibility and efficacy of cognitive behavioral therapy has been subject of discussion in most of the studies. In this regard, Barry et al. (2019) conducted a study that aimed at evaluating the acceptability, feasibility, and efficacy of cognitive behavioral therapy use in opioid use disorder as well as chronic pain. The researchers used 21 patients who were assigned to cognitive behavioral therapy and 18 assigned to the methadone drug counseling. The results of the investigation showed that cognitive behavioral therapy was associated with a high rate of abstinence, satisfaction, and sustained effectiveness when compared to those assigned to the methadone counseling group. The feasibility, efficacy, and acceptability of cognitive behavioral therapy was also supported.
The use of cognitive behavioral therapy in alcohol abuse and drug addiction is effective in practice. Most of the studies conducted on the topic show that it improves withdrawal and dependence symptoms among the affected populations. According to López et al. (2021), cognitive behavioral therapy interventions such as contingency management is effective in reducing the use of drugs such as cocaine and methamphetamine. The authors also note that cognitive behavioral therapy interventions such as motivational interviewing, prevention support groups, and social support groups are effective in reducing the use and abuse of marijuana. Optimum benefits are reported in cases where cognitive behavioral therapy is used alongside pharmacotherapy. According to Ray et al. (2020), cognitive behavioral therapy with pharmacotherapy is highly effective when compared to pharmacology and usual care. The enhanced benefits can be seen from reduced risk for relapse and sustained effectiveness. Kiluk et al. (2018) reported similar findings in their research where innovative interventions that include computerized and clinician delivered cognitive behavioral therapy were found to be highly effective in substance use disorders when compared to the usual care. The researchers found that the intervention reduced the frequency of drug use with continuous benefits post-implementation of the study. Therefore, healthcare providers should consider incorporating cognitive behavioral therapy plus pharmacotherapy in the treatment plan for patients with alcohol and substance abuse disorders.
Issues of APRN Practice
APRNs can play a proactive role in the delivery of cognitive behavioral therapy to patients with alcohol and substance abuse disorders. However, a number of issues impede their ability to undertake this role. Firstly, issues such as the need for additional training and lack of credentialing for APRNs on cognitive behavioral therapy impede their role in patient care. Effective frameworks are needed in nursing practice to provide insights into the training and licensure requirements for APRNs interested in cognitive behavioral therapy. The other issue that impede the delivery of cognitive behavioral therapy by APRNs in clinical settings is the inadequacy of resources. Healthcare institutions often face the challenge of inadequate resources to train its mental healthcare providers to offer cognitive behavioral therapy. There is also the lack of a formally recognized reimbursement scheme for nurse practitioners involved in the provision of cognitive behavioral therapy for patients’ alcohol and substance abuse disorders (Yohannes, 2018). Therefore, the above issues should be addressed to increase the roles of APRNs in the use of psychotherapy in substance abuse disorders.
Future Development and Research
Cognitive behavioral therapy has been largely explored in Western nations to examine its effectiveness in different mental health problems including alcohol and substance abuse disorders. Its use in ethnic minorities and refugees however remain unexplored. Therefore, future studies should aim at exploring its effectiveness in this populations. There is also a need for future studies to examine the effectiveness, efficacy, and safety of culturally-adaptive cognitive behavioral therapy in alcohol and substance abuse disorders.
Alcohol and substance use addiction is a critical health problem affecting the American populations. The disorder is associated with low quality of life as well as loss of social and occupational productivity. Cognitive behavioral therapy is a psychological intervention that is recommended for use in the management of alcohol and substance abuse disorders. Cognitive behavioral therapy helps patients develop effective coping knowledge and skills for managing substance abuse disorders. The existing evidence shows that optimum benefits are seen in the use of pharmacotherapy and cognitive behavioral therapy. Culturally appropriate cognitive behavioral therapy is needed in the current practice of mental health. Therefore, future studies should explore the effectiveness of culturally-adaptive cognitive behavioral therapy in ethnic minority groups.
- Ash, M., Harrison, T., Pinto, M., DiClemente, R., & Negi, L. T. (2021). A model for cognitively-based compassion training: Theoretical underpinnings and proposed mechanisms. Social Theory & Health, 19(1), 43–67. https://doi.org/10.1057/s41285-019-00124-x
- Barry, D. T., Beitel, M., Cutter, C. J., Fiellin, D. A., Kerns, R. D., Moore, B. A., Oberleitner, L., Madden, L. M., Liong, C., Ginn, J., & Schottenfeld, R. S. (2019). An evaluation of the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy for opioid use disorder and chronic pain. Drug and Alcohol Dependence, 194, 460–467. https://doi.org/10.1016/j.drugalcdep.2018.10.015
- Hinton, D. E., & Patel, A. (2017). Cultural adaptations of cognitive behavioral therapy. Psychiatric Clinics, 40(4), 701–714.
- Ibemere, J. C. (2020). Improving Participation in Cognitive Behavioral Therapy (CBT) Using Education among Adult Patients with Depression [PhD Thesis]. Brandman University.
- Kapadia, S. V. (2020). The effectiveness of cognitive behavioral therapy for substance use disorders and the challenges in treating this client group: A review. International Journal of Indian Psychology, 8(4). https://doi.org/10.25215/0804.112
- Kiluk, B. D., Nich, C., Buck, M. B., Devore, K. A., Frankforter, T. L., LaPaglia, D. M., Muvvala, S. B., & Carroll, K. M. (2018). Randomized Clinical Trial of Computerized and Clinician-Delivered CBT in Comparison With Standard Outpatient Treatment for Substance Use Disorders: Primary Within-Treatment and Follow-Up Outcomes. American Journal of Psychiatry, 175(9), 853–863. https://doi.org/10.1176/appi.ajp.2018.17090978
- López, G., Orchowski, L. M., Reddy, M. K., Nargiso, J., & Johnson, J. E. (2021). A review of research-supported group treatments for drug use disorders. Substance Abuse Treatment, Prevention, and Policy, 16(1), 51. https://doi.org/10.1186/s13011-021-00371-0
- Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Tonigan, J. S., & Carroll, K. (2019). A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition. Journal of Consulting and Clinical Psychology, 87(12), 1093–1105. https://doi.org/10.1037/ccp0000447
- Naeem, F. (2019). Cultural adaptations of CBT: A summary and discussion of the Special Issue on Cultural Adaptation of CBT. The Cognitive Behaviour Therapist, 12. https://doi.org/10.1017/S1754470X19000278
- Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis. JAMA Network Open, 3(6), e208279–e208279. https://doi.org/10.1001/jamanetworkopen.2020.8279
- Roos, C. R., Maisto, S. A., & Witkiewitz, K. (2017). Coping mediates the effects of cognitive–behavioral therapy for alcohol use disorder among out-patient clients in Project MATCH when dependence severity is high. Addiction, 112(9), 1547–1557. https://doi.org/10.1111/add.13841
- Sadock, B. J., & Sadock, V. A. (2020). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins.
- Yohannes, A. M. (2018). Nurse-led cognitive behavioural therapy for treatment of anxiety in COPD. ERJ Open Research, 4(4), 00221–02018. https://doi.org/10.1183/23120541.00221-2018